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• <br /> - <br /> CIIY ul 1USEME PSS Ut Ell(ENt POS <br /> 1820 KOOsEVELT BLVD I.ITY 01 two*: CIIY PUS 828 ROOSEVELT01 cUVU . <br /> EUGENE. OR. 97402-4159 1820 Ki)(i:.LVE1 T BLVD 1 <br /> i 11820 Ø . X7102-4159 <br /> 541-682 4012 tl1GFNl:. OR. 97402-4159 541-682 4812 <br /> 541-682-4812 � <br /> REPRINT RII R PRINT <br /> Afund Re nd <br /> zxxxxxill zzzzzzzxxzzz zxzzzzxzzzz Entry Method: Manual <br /> VISA Entry Method: Manual VISA Entry Method: Manual -• 'lSR <br /> Total: $ 10.00 , \ <br /> Total: $ 100.00 Total: $ 75.00 <br /> 05/09/16 15:49:02 6/6/16 17:16:19 0549/16 16:41:34 <br /> Inv a: 480000005 Inv N: 0000N007 Inv u: 000006%6 <br /> Rvvrvd: Online : MAvrvd: Online APprvd: Online <br /> I agree to oar above total amount I agree to oar above total amountI agree to aar stove total amount <br /> according to card d issuer agreement according to card issuer agreement according to card issuer agreement <br /> iMerchant agreement if credit voucheri (Merchant agreement if credit voucher) (Merchant agreement if credit voucher) <br /> rc� <br /> A <br /> i & M5 iA._13 - Y Ls U c e- ..- x � --------- --- - --(`--- <br /> . I IA 6 'llwnl Copy `/� <br /> Merchant COPY Merchant Coat. • —q"M+, M <br /> THANK YOU! DIME YOU! ((I iORedIHFlN(YOUL <br /> ltl . ._ - - <br /> I <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 4 <br /> 1 <br /> 0 <br /> NI <br />